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Journal of Orthodontics, Vol. 34, 2007, 000–000 supernumerary: a complication ofspace closure A. ShahLiverpool Road Health Centre, Luton, UK S. HiraniLuton and Dunstable Hospital, Luton, UK This case report describes a situation in which a mandibular supernumerary developed during orthodontic treatment andprevented space closure.
Key words: Late forming supernumerary, space closure complication, radiographs Received 29th December 2006; accepted 20th March 2007 mode of inheritance has been suggested by the observa- tion that males are affected twice as much as females.2 Supernumerary teeth are described as those in excess Supernumeraries have a tendency to begin their devel- when compared to the normal dental formula.1 Their opment later than their corresponding normal teeth.3,4 reported prevalence ranges between 0.1 and 3.8% in the An unerupted supernumerary tooth may be found by permanent dentition, and between 0.3 and 0.8% in the chance during radiographic examination, with no primary dentition.2,3 Potential complications of super- numerary teeth include failure of eruption, displace- Classification of supernumerary teeth is based on ment, rotation or root resorption of adjacent teeth, location or morphology.2 Ninety to ninety-eight per cent crowding, abnormal diastema, cyst formation and occur in the maxilla, most commonly in the premaxilla.1 The majority of cases reporting one or two super- The incidence of supernumerary premolars is reported numerary teeth involve the anterior maxilla, followed by to be 1 in 10 000 individuals.5 Several studies have been the mandibular premolar region. There are variations in conducted in order to determine their prevalence.
the reported relative frequencies of supernumerary teeth Rubenstein6 reported 0.64% prevalence of supernumer- in other regions.2 Supernumerary maxillary premolars ary premolars. Grahnen and Lindahl7 reported that have variable morphology, but are predominantly mandibular premolar supernumeraries occur in 0.29% conical. Those in the mandible tend to have the shape of the general population. Mandibular premolar super- of a normal premolar crown.11 A number of well known numeraries have been reported to represent 6.6%,3 conditions, including cleidocranial dysplasia, Gardner’s 9.2%8 and 14%7 of all supernumeraries. The wide syndrome and cleft lip and palate can predispose to the variation in percentages reported can be attributed to development of supernumerary teeth.2,12,13 A study on variations in size of study, age, range, racial composition multiple supernumerary teeth without associated sys- temic conditions or syndromes, found the highest The aetiology of supernumerary teeth is unclear and frequency of occurrence (45%) in the mandibular various factors, namely genetic and environmental, have been suggested.2 Supernumerary teeth may result from appear in more than one quadrant, are more likely to hyperactivity of the dental lamina, proliferation of develop in the mandible than the maxilla and are more dental lamina remnants or cell rests, or division of tooth germs.9 The familial nature of supernumerary There have been numerous case reports documenting teeth may be supported by findings that they are more the presence of supernumeraries in the mandibular common in relatives of affected children.10 A sex-linked premolar region.4,5,9,11,12,14,15,17–28 Several cases have Address for correspondence: Mr Ashish Shah, Dental Officer,Liverpool Road Health Centre, 9 Mersey Place, Luton LU1 1HH,UK. Email: [email protected]# 2007 British Orthodontic Society been reported in which supernumeraries have developedduring orthodontic treatment.6,11,14,17–19,28 This reportdescribes how a late developing supernumerary in thepremolar region had an effect on the proposedorthodontic space closure. This supernumerary was not apparent,radiographically, prior to treatment. Although thepotential of supernumeraries to prevent space closurehas been recognized,4,11,14 to our knowledge, there hasbeen A 13-year-old autistic Caucasian male was referred to the Orthodontic department at Guy’s Hospital fortreatment of a Class II division I malocclusion. The history and subsequent clinical examination provided noinformation of a remarkable nature. There was no Attain Class I incisor and molar relationships In order to avoid extractions, medium pull headgear could have been used to distalize the maxillary buccal N Acceptable facial profile; lips on Ricketts’s E-Plane; segments. However, the patient refused to wear head- gear and his parents felt he would be unable to tolerate approach was thus required, so the following treatment plan was tailored to the patient’s needs: N Mild mandibular arch crowding (approximately N Extraction of maxillary first premolars and mandi- N Severe maxillary arch crowding (approximately 9 mm) with exclusion of maxillary right canine.
Maxillary left canine unerupted with insufficient N Upper and lower fixed appliances, with or without Class II intermaxillary elastic traction.
N Molar relationship 1/2 unit Class II bilaterally The patient was treated with pre-adjusted edgewise The pre-treatment dental panoramic tomograph (DPT) appliances. His treatment took 20 months until debond.
(Figure 1) showed normal dental development for the Towards the end of treatment, spaces remained in the patient’s age, with no presence of supernumeraries.
regions of the extracted premolars. Class II intermax-illary elastic traction was utilized. However, the patient was not consistently compliant with this treatmentregime. Elastic chain was used in order to close the N Skeletal: Class II skeletal base with mandibular mandibular right premolar space and correct the lower centreline, which was initially 3 mm to the left. After a few visits, it was apparent that this space was not closing. It was decided to take a DPT and lateral Dental panoramic tomograph showing developing supernumerary in the lower right premolar region cephalogram in order to determine why space closurewas difficult, while simultaneously assessing the labialinclinations of the anterior teeth. These radiographsconfirmed the presence of a late-forming supernumeraryin the lower right premolar region (Figures 2 and 3). Oncareful clinical inspection of this region, the super-numerary could not be palpated buccally or lingually.
This confirmed the supernumerary was in the line of the Lateral cephalogram also confirming the presence of a supernumerary while showing the labial inclinations of the anterior There was no change to the maxillary or mandibularrelationship, as growth modification or surgery was not centreline orthodontically. However, if the extraction involved excessive bone removal, this may have com- The maxillary dentition was well aligned and the plicated space closure. After careful explanation of the canines were in the line of the arch. The mandibular treatment options, the patient and parents felt the risks dentition was aligned. However, approximately 3 mm of of extraction of the supernumerary outweighed the space remained in the lower right second premolar benefits of space closure. It was therefore decided to region. All space in the lower left quadrant was closed leave the supernumerary in situ and accept the lower using elastic chain. The incisor relationship was Class I, right space and centreline discrepancy.
but the lower centreline was 3 mm to the left.
It was explained to both the patient and parents that Consequently, the left buccal segment relationship was the lower right mandibular supernumerary would 1/2 unit Class II and the right buccal segment relation- require periodic clinical and radiographic monitoring by his general dental practitioner. If this tooth were toerupt, it would erupt lingually.
The presence of the lower right mandibular super- numerary was unexpected and prevented attainment of a Class I buccal segment relationship bilaterally.
Facial aesthetics were preserved and there was no supernumerary teeth may cause a variety of dis- turbances to the developing permanent dentition. Theymay cause delayed eruption, displacement, rotation, In this case, it was believed that the surgical and general flaring, or root resorption of the adjacent permanent anaesthetic risks of removing the supernumerary could not be justified. Surgical risks included damage to the development of dentigerous or primordial cysts.2,4,5,20,21 lingual and mental nerves and adjacent teeth. If the As has been demonstrated in this report, they may supernumerary was extracted, it may have then been also create an unexpected complication to orthodontic possible to close the space and correct the lower The recommended management of supernumerary 2. Rajab LD, Hamdan MAM. Supernumerary teeth: review of teeth is extraction, unless removal is hazardous to the literature and a survey of 152 cases. Int J Paediatr Dent adjacent teeth and structures, contraindicated by a compromised medical status, or if the supernumerary 3. Stafne, EC. Supernumerary teeth. Dental Cosmos 1932; 74: tooth can be used for orthodontic purposes.21,22 It is important to monitor unerupted supernumeraries at 4. Scanlan PJ, Hodges SJ. Supernumerary premolar teeth in reasonable intervals. The patient should be kept siblings. Br J Orthod 1997; 24(4): 297–300.
informed at all times of the possible complications such 5. Poyton GH, Morgan GA, Crouch SA. Recurring super- numerary mandibular premolars: report of a case ofpostmature development. Oral Surg Oral Med Oral Pathol1960; 13: 964–66.
Complications during orthodontic space closure 6. Rubenstein LK, Lindauer SJ, Isaacson RJ, Germane N.
Reasons for failure of space closure in cases with sliding Development of supernumerary premolars in an orthodon- tic population. Oral Surg Oral Med Oral Pathol 1991; 71(3):392–95.
7. Grahnen H, Lindahl B. Supernumerary teeth in the permanent dentition: a frequency study. Odontol Revy N medications including non-steroidal anti-inflammatory 8. Bodin I, Julin P, Thomsson M. Hyperdontia. I. Frequency and distribution of supernumerary teeth among 21,609 patients. Dentomaxillofac Radiol 1978; 7(1): 15–17.
9. Moore SR, Wilson DF, Kibble J. Sequential development of multiple supernumerary teeth in the mandibular pre- Intra-alveolar causes include retained roots and super- molar region—a radiographic case report. Int J Paediatr numeraries. If the cause cannot be determined, a radiograph should be considered. This could reveal a 10. Brook AH. A unifying aetiological explanation for anoma- supernumerary preventing space closure.
lies of human tooth number and size. Arch Oral Biol 1984; 11. Breckon JJ, Jones SP. Late forming supernumeraries in the mandibular premolar region. Br J Orthod 1991; 18(4): 329– Difficulties were encountered when attempting to close the mandibular right premolar space, so radiographic 12. Kocadereli I, Ciger S, Cakirer B. Late-forming super- investigation was required to determine any intra- numeraries in the premolar regions. J Clin Orthod 1994; alveolar factor preventing tooth movement. As the patient was approaching the end of active treatment, it 13. Yusof WZ. Non-syndrome multiple supernumerary teeth: was decided to take a DPT and lateral cephalogram in literature review. J Can Dent Assoc 1990; 56(2): 147–49.
order to help determine why space closure was difficult, 14. Cochrane SM, Clark JR, Hunt NP. Late developing while simultaneously assessing the labial inclinations supernumerary teeth in the mandible. Br J Orthod 1997; of the anterior teeth, thus minimizing exposure to 15. King NM, Lee AM, Wan PK. Multiple supernumerary premolars: their occurrence in three patients. Aust Dent J The possibility of supernumerary teeth interfering with occlusal development or orthodontic mechanics 16. Solares R, Romero MI. Supernumerary premolars: a such as space closure should always be borne in literature review. Pediatr Dent 2004; 26(5): 450–58.
mind.14,17 On occasion, treatment goals may need to 17. Hall A, Onn A. The development of supernumerary teeth in be modified. Although a DPT radiograph should not be the mandible in cases with a history of supernumeraries in taken routinely during space closure, it may prove the pre-maxillary region. J Orthod 2006; 33(4): 250–55.
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29. Tyrovola JB, Spyropoulos MN. Effects of drugs and 24. Nayak UA, Mathian VM, Veerakumar. Non-syndrome systemic factors on orthodontic treatment. Quintessence associated multiple supernumerary teeth: a report of two cases. J Indian Soc Pedod Prev Dent 2006; 24(5): 11–14.
30. Arias OR, Marquez-Orozco MC. Aspirin, acetaminophen, 25. Kalra N, Chaudhary S, Sanghi S. Non-syndrome multiple and ibuprofen: their effects on orthodontic tooth move- supplemental supernumerary teeth. J Indian Soc Pedod Prev ment. Am J Orthod Dentofacial Orthop 2006; 130(3): 364– Journal: Journal of OrthodonticsPaper: H1Title: A late-forming mandibular supernumerary: a complication of space closure Dear AuthorDuring the preparation of your manuscript for publication, the questions listed below have arisen. Please attend tothese matters and return this form with your proof. Many thanks for your assistance Author: Please confirm the shorttitle.

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